Provider Demographics
NPI:1033126651
Name:DAVIS, HORACE J (DO)
Entity Type:Individual
Prefix:DR
First Name:HORACE
Middle Name:J
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25373 VAN DYKE AVE
Mailing Address - Street 2:
Mailing Address - City:CENTER LINE
Mailing Address - State:MI
Mailing Address - Zip Code:48015-1425
Mailing Address - Country:US
Mailing Address - Phone:586-261-2500
Mailing Address - Fax:
Practice Address - Street 1:25373 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:CENTER LINE
Practice Address - State:MI
Practice Address - Zip Code:48015-1425
Practice Address - Country:US
Practice Address - Phone:586-261-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007157208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI200000004050OtherPHYSICIAN HEALTH PLAN
MI1917979Medicaid
MI06617AOtherCALHOUN HEALTH PLAN
MI0851338774OtherBCBS
MI0851338774Medicare ID - Type Unspecified
MI1917979Medicaid